DEPARTMENTAL CERTIFICATION. The Department certifies that in the case of a self-employed Contractor, the Department has completed and attached the following file: Employee vs. Independent Provider Checklist Ctrl+click to open link
DEPARTMENTAL CERTIFICATION. Department is to complete this section. Attach additional pages if necessary. Contractor and authorized officer sign PART II. TERMS AND CONDITIONS.
1. Name of Contractor 2. Permanent Address
3. Address for Invoice Payments: _
4. Describe the nature of service or scope of duties to be performed and how services will be provided.
5. Briefly describe the selection criteria used for this Contractor (e.g., education, training).
6. Anticipated duration and costs of proposed professional services activity: Dates or Period of Performance through Fee for Services: $ per (lump sum, day, hour, etc.) Other expenses (hotel, travel, meals, etc.) TOTAL fee for services and expenses (not to exceed without written amendment) Funding Source Expiration date (if Grant) / / *For an individual, please complete and attach the Employee vs. Independent Contractor Checklist
DEPARTMENTAL CERTIFICATION. I have verified the identification of the customer requesting this service. Construction Science Xxxxxxx Xxxxxxx xxxxxxxx@xxxx.xxx Department Name Dep. Rep Signature Dep. Rep Name Dep. Rep Email
DEPARTMENTAL CERTIFICATION. Department is to complete this section. Attach additional pages if necessary. Contractor and authorized officer sign PART II. TERMS AND CONDITIONS.
1. Name of Contractor: 2. Permanent Address
3. Address for Invoice Payments:
4. Describe the nature of service or scope of duties to be performed and how services will be provided.
5. Briefly describe the selection criteria used for this Contractor (e.g., education, training).
6. Do you contemplate continuing or recurring work with this Contractor? Yes No
7. Has the Contractor provided this or similar service to Department within the last 12 months? Yes No
8. Will a Brown employee determine the specific hours to be worked, the way services will be performed, or otherwise supervise or direct the work of the Contractor? Yes No
9. Will the services be performed at a Brown location? Who will determine the hours the services will be performed? Brown Yes No Contractor
10. Will Contractor receive any training, guidance, or assistance, other than audio or video presentation aids, or be provided with equipment, tools or supplies? If so, Yes No please describe.
11. If assistance is needed to perform the services
a.) will the assistance be performed by a Brown employee or employees? Yes No b.) will the Contractor hire his/her own help? Yes No
12. Is the recommended Contractor a current or former employee of Xxxxx? Yes No
13. Is the Contractor related to any Brown employee who has controlling interest in or relationship to the performance of these services? Yes No
14. Is the Contractor actively engaged in providing these or similar services to other organizations? Yes No If so, who are clients?
15. U.S. Citizen Yes No (For non-resident aliens only) Visa Type: IRS FORM 8233 attached? Yes No
16. Anticipated duration and costs of proposed professional services activity: Dates or Period of Performance / / through / / Fee for Services: $ per (lump sum, day, hour, etc.) Total $ Other expenses (hotel, travel, meals, etc.) $ TOTAL fee for services and expenses (not to exceed without written amendment) $ Account number to be charged Expiration date (if 5-ledger) / / Certified by Department Head or Designee Name and Title: Date / /
DEPARTMENTAL CERTIFICATION. Department is to complete this section. Attach additional pages if necessary. Contractor and authorized officer sign PART II. TERMS AND CONDITIONS.
1. Name of Contractor _ _ 2. Permanent Address _ _
3. Address for Invoice Payments: _
4. Describe the nature of service or scope of duties to be performed and how services will be provided.
5. Briefly describe the selection criteria used for this Contractor (e.g., education, training).
6. Anticipated duration and costs of proposed professional services activity: Dates or Period of Performance through Fee for Services: $ per (lump sum, day, hour, etc.) Other expenses (hotel, travel, meals, etc.) TOTAL fee for services and expenses (not to exceed without written amendment) Funding Source Expiration date (if Grant) / / *Please complete and attach the Employee vs. Independent Contractor Checklist
